Note that, even in 1986, the Committee on Veterans’ Affairs was savvy to, and advocating the use of metadata (then called the “data dictionary – a roadmap to the database.” It understood its use in VistA (then called DHCP), its role in portability (then with the Indian Health Service), and hopes to use it for the Department of Defense’s Composite Health Care System.

Today, metadata is a household word, given the NSA’s use of it. But it reflects an entirely different perspective on how we view complex systems.

Imagine a complex system, represented by millions of dots, with even more connectors between the dots. We can think of the dots as representing the “data” in the system, and the connectors (links) representing the “metadata” in the system.

This perspective generates an overwhelming number of dots and links, well beyond any human capacity to understand.

One way to approach this complexity I’ll call the “Dots-first” approach. This approach tries to categorize the dots, pigeonholing them into a predefined hierarchy of terms: “A place for every dot, and every dot in its place.” This goes back to Aristotle, and the law of the excluded middle. Something is either A or Not A, but not both. We just keep applying this “law” progressively until we get a tidy Aristotelian hierarchy of categories. Libraries filed their books this way, according to the Dewey Decimal system. If you wanted to find a book, you could look in a card catalog for title, author, and subject, then just go to the shelves to find the book. The links between the dots are largely ignored. For example, it would be impossible to maintain the card catalog by all the subjects referenced in all the books, or all of the references to other books and papers. Order is maintained by ignoring links that don’t fit the cataloging/indexing system.

An alternative approach I’ll call the “Links-first” approach. This approach focuses on the links, not the dots. It revels in lots of links, and manages them at a meta-data level, maintaining the context of the information. It can work with the Dots-first categorization schemes, but it doesn’t need them. This is the approach taken by Google. It scans the web, indexing information, growing the context of the dot with every new link established.

If a book had a Dewey Decimal System number assigned to it, Google would pick it up as just another piece of metadata. Users could search for the book using it, but why would they? Why revert to the “every dot in its place and a place for every dot” scheme when you can use the much richer contextual search that Google provides.

Sonny Montgomery – in 1986 – was advocating the “Links-first” approach that we pioneered in VistA. This approach came up again in the metadata discussions of the PCAST report.

Bureaucracies typically favor to focus on the dots. If a Dewey Decimal System isn’t working well enough, the solution is to add more digits of precision to it, more librarians to catalog the books, and larger staffs, standards committees, and regulation to insure that the dots all stay in their assigned pigeonholes.

This is what is happening with ICD10 today. After the October 2014 roll out, we will now have the ability to differentiate “W59.21 Bitten by turtle” and “W59.22 Struck by turtle” as two distinct dots in the medical information universe. Unfortunately, we are lacking dots to name tortoises, armadillos, or possums. Struck By Orca (both the name of the book as well as an ICD10 code) provides some artistic insight into the new coding system.

The continued expectation that we can understand medicine from a “Dots-first” approach is a travesty in today’s world of interconnection, rapidly growing knowledge and life-science discoveries, and the world of personalization. People use Google, not card-catalogs, to find their information, and do so in a much richer, quicker, and informative way than anything before in human history.

The “Dots-first” thinkers will panic at the emergence of a “links-first” metadata approach. How can we have establish order if we don’t have experts reviewing the books, applying international standards, and librarians carefully typing and filing the catalogs?

One of the criticisms in the early days of VistA that it’s metadata-driven model would lead to “Helter Skelter” development, and that only centralization could make things orderly. (Helter-Skelter was the name of the Charles Mansion murder movie at the time, so the term carried a lot of linguistic baggage with it.) They could see only the Dots-first framework, and the ensuing failures of the centralized, waterfall development of $100m+ megaprojects has continually proven that their approach doesn’t work. Yet, they continue to blame their failures on the decentralized, metadata-driven core of the system.

There are technologies that address this, such as the Semantic Web or Linked Data initiatives. But I’m afraid that there is so much money to be made “improving” the medical Dewey Decimal Systems and patching up all the holes in the Dots-first kludges that it seems to be a tremendous uphill battle.

Hello National Health Service. I’m glad that you are looking in to the adaptation of VA’s VistA into your IT activities over there. I’ve been an outside observer and sometimes consultant to various NHS groups for years, and am particularly interested in helping you understand the VistA phenomenon. Trying to understand VistA by looking at its source code is like trying to understand Wikipedia by studying the PHP of the underlying wiki. The wealth is in the community of users, not the source code.

By way of introduction, as a VA employee, I was one of the original software architects for VistA. I then moved to Science Applications International Corporation (SAIC) in San Diego, Ca. where I played the same role for the US Dept. of Defense’s Composite Health Care System (CHCS). These are the two largest health care systems in the US, so I’ve seen issues of scale, portability, bureaucratic infighting, and no end of technical argument about how to do things. Internationally, I’ve designed or consulted on health IT in France, Spain, Switzerland, Finland, Japan, Australia, and Nigeria. I’ve testified before the US Senate Committee on Veterans’ Affairs on the Future of Health IT.

I spent some years looking at future technology for the VA (here are some of my papers), then took an early retirement from my position as VP and Chief Scientist at SAIC to broaden my interests of applying technology for humanitarian, philanthropic, and educational uses. I took a year as a Visiting Scholar at Stanford University’s Digital Visions Program, founded a humanitarian think tank called the Uplift Academy, in which I’ve developed a workshop format I call Slow Conversations.

I was one of the initial members and leaders of the Underground Railroad, the “skunkworks” group that did the original design of the system that was to become VistA. I gave an Unlimited Free Passage certificate to Chuck Hagel, then of the VA, now US Secretary of Defense. The Hardhats were another group, consisting of the programmers who were doing the actual implementation of the technology. The Underground Railroad included a more eclectic group of people interested in the broader aspects of the issues of the role of Health IT in the VA. Here are some videos of speeches at some Underground Railroad Banquets over the years.

As Chief of Conceptual Integrity of the Underground Railroad, I took the the ethos we were building very seriously. In addition to my programming interests, I was a keen student of linguistics, particular the Whorf/Sapir hypothesis, Ludwig Wittgenstein, and S.I. Hayakawa. I was building a speech community to talk about health, across the organizational stovepipes so prominent in large bureaucracies.

I’ve started the New Health Project to look at the broader implications of health care and information technology. We’ve had two workshops in California, and one at the W3C offices at MIT. Speakers have included Sci Fi writer/futurist David Brin, Sci Fi writer Vernor Vinge, who coined the term “Technological Singularity,” Peter Norvig, Director of Research at Google, and others.

I would be very interested in helping NHS understand the VistA Ethos, as well as establish a bridge between US and NHS to continue the conversation.

P.S. The world of VistA as seen within Washington DC beltway is radically different from what happens in the field. DC operates from a top-down “power” model, while VistA thrived as a bottom-up “energy” model. So, while I’m sure that there is lots of value to power-based London/Washington connections, the real value to accrue would come from connecting a broader group of the folks who are actually using the software.

I would be happy to help communicate and hopefully, enhance, the VistA ethos.